abdominal pain in the pediatric patient tim weiner, m.d. dept. of surgery university of north...

ABDOMINAL PAIN in the PEDIATRIC PATIENT

Tim Weiner, M.D.Dept. of Surgery

University of North Carolina

at Chapel Hill

In General

Common problems occur commonly– intussusception in the infant– appendicitis in the child

The differential diagnosis is age-specific In pediatrics most belly pain is non-surgical

– “Most things get better by themselves. Most things, in fact, are better by morning.”

Bilous emesis in the infant is malrotation until proven otherwise

A high rate of negative tests is OK

The History

Pain (location, pattern, severity, timing)– pain as the first sx suggests a surgical problem

Vomiting (bile, blood, projectile, timing) Bowel habits (diarrhea, constipation, blood,

flatus) Genitourinary complaints Menstrual history Travel, diet, contact history

Diagnosis by Locationgastroenteritisearly appendicitisPUDpancreatitis

non-specificcolicearly appendicitis

constipationUTIpelvic appendicitis

biliaryhepatitis

appendicitisenteritis/IBDovarian

spleen/EBV

constipationnon-specificovary

The Physical Examination

Warm hands and exam room Try to distract the child (talk about pets) A quiet, unhurried, thorough exam Plan to do serial exams Do a rectal exam

The Abdominal Examination

breath soundsMurphy’s sign“sausage”

Dance’s signreboundtender at McBurney’s pointcecal “squish”

herniastorsion

breath soundsspleen edge

constipationRovsing’s sign

Relevant Physical Findings

Tachycardia Alert and active/still and silent Abdominal rigidity/softness Bowel sounds Peritoneal signs (tap, jump) Signs of other infection (otitis, pharyngitis,

pneumonia) Check for hernias

Blood in the Stool

Newborn– ingested maternal blood, formula intolerance, NEC, volvulus,

Hirschsprung’s

Toddler– anal fissures, infectious colitis, Meckel’s, milk allergy, juvenile polyps,

HUS, IBD

2 to 6 years– infectious colitis, juvenile polyps, anal fissures, intussusception, Meckel’s,

IBD, HSP

6 years and older– IBD, colitis, polyps, hemorrhoids

Blood in the Vomitus

Newborn– ingested maternal blood, drug induced, gastritis

Toddler– ulcers, gastritis, esophagitis, HPS

2 to 6 years– ulcers, gastritis, esophagitis, varices, FB

6 years and older– ulcers, gastritis, esophagitis, varices

Further Work-up

CBC and differential Urinalysis X-rays (KUB, CXR) US Abdominal CT Stool cultures Liver, pancreatic function tests (Rehydrate, ?antibiotics, ?analgesiscs)

Relevant X-ray Findings

Signs of obstruction– air/fluid levels

– dilated loops

– air in the rectum?

Fecalith Paucity of air in the right side Constipation

Operate NOW

Vascular compromise– malrotation and volvulus

– incarcerated hernia

– nonreduced intussusception

– ischemic bowel obstruction

– torsed gonads

Perforated viscus Uncontrolled intra-abdominal bleeding

Operate SOON

Intestinal obstruction Non-perforated appendicitis Refractory IBD Tumors

Appendicitis

Common in children; rare in infants Symptoms tend to get worse Perforation rarely occurs in the first 24 hours The physical exam is the mainstay of

diagnosis Classify as simple (acute, supparative) or

complex (gangrenous, perforated)

Incidental Appendectomy

Can be done by inversion technique Absolute indication

– Ladd’s procedure

Relative indications– Hirschsprung’s pullthrough– Ovarian cystectomy– Intussusception– Atresia repair– Wilms’ tumor excision– CDH

Intussusception

Typically in the 8-24 month age group Diagnosis is historical

– intermittent severe colic episodes

– unexplained lethargy in a previously healthy infant

Contrast enema is diagnostic and often therapeutic

Post-op small bowel intussusception

The “Medical Bellyache” Pneumonia Mesenteric adenitis Henoch-Schonlein Purpura Gastroenteritis/colitis Hepatitis Swallowed FB Porphyria Functional ileus UTI Constipation IBD “flare” rectus hematoma

Laparoscopy

Diagnosis– non-specific abdominal pain– chronic abdominal pain– female patients– undescended testes– trauma

Treatment– appendicitis– Meckel’s diverticulum– cholecystitis– ovarian detorsion/excision– lysis of adhesions

The Neurologically Impaired Patient

The physical exam is important for non-verbal patients

The history is important for the spinal cord dysfunction patient

Close observation and complementary imaging studies are necessary

The Immunologically Impaired Patient

A high index of suspicion for surgical conditions and signs of peritonitis may necessitate operation– perforation

– uncontrolled bleeding

– clinical deterioration

Blood product replacement is essential Typhlitis should be considered; diagnosis is

best established by CT

The Teenage Female

Menstrual history– regularity, last period, character, dysmenorrhea

Pelvic/bimanual exam with cultures Pregnancy test/urinalysis US Laparoscopy Differential diagnosis

– mittelschmerz, PID, ovarian cyst/torsion, endometriosis, ectopic pregnancy, UTI, pyelonephritis

In Summary

“My dear surgeon, beware- haste not,Pleads the child silently,Listen to my mother, and then-Examine and again examine me:This will improve my lotAnd assure you accuracy.”